A knowledge of the exchanges of energy and water over the terrestrial surface is the first step to understand the ecohydrological mechanisms, particularly in water-limited ecosystems in the dryland environments. However, patterns of energy exchange and evapotranspiration (ET) are not well understood in the oasis-desert ecotone, which plays an important role in protecting oasis against the threat of desertification in northwestern China’s arid regions. Here the continuous measurements of surface energy fluxes were made using eddy covariance in conjunction with auxiliary measurements for two years (2014-2015) at a shrubland within an oasis-desert ecotone in the arid regions, northwestern China. Statistical analysis on 30-min time scale indicates that about 50% of daytime net radiation (Rn) over the shrubland is dissipated as H on average, which peaks in spring; one third Rn is consumed by soil heat flux (G). Only 9% of Rn was consumed for latent heat flux (λE), which peaks in summer (21% in 2014 and 16% in 2015), corresponding to the season with highest rainfall among all seasons. Daily mean ET is about 1 mm·d−1 during growing season of the shrub species. The rapid and transient increase in ET occurs following a rainfall event. A switch in surface soil moisture from 0.04 to 0.11 m3·m−3 causes an increase in Rn by about 11% and λE by 151% at the shrubland, respectively. Accumulated annual ET were 195 and 181 mm in 2014 and 2015, respectively, exceeding the corresponding P by about 87 and 77 mm, indicating that groundwater may be another important source of water for ET over the shrubland aside from P. These results provide valuable insight into the mechanisms of sustaining energy and water balance at the ecotone, and then produce some management guidelines for allocating water resources and protecting vegetation.

Complex civil structures require the cooperation of many building materials. However, it is difficult to accurately monitor and evaluate the inner damage states of various material systems. Based on a convolutional neural network (CNN) and the acoustic emission (AE) time-frequency diagram, we used the transfer learning method for classifying the AE signals of different materials under external loads. The results show the CNN model can accurately classify cracks that come from different materials based on AE signals. The recognition accuracy can reach 90% just by re-training the full connection layer of the pre-trained model, and its accuracy can reach 97% after re-training the top 2 convolutional layers of this model. A realization of cracking source identification mainly depends on the differences in mineral particles in materials. This work highlights the great potential for real-time and quantitative monitoring of the health status of composite civil structures.

Mini Commentary – BJOG

Anaemia in pregnancy remains a global health problem In this issue of BJOG Hull et al …… et al report on an important study from South Africa regarding anaemia in pregnancy and the response to iron therapy. They report that in HIV-positive women the response was slower than in HIV-negative women. The underlying causes of anaemia varied and included iron deficiency (as assessed by ferritin levels) as well as concurrent infections (urinary tract infections and tuberculosis)Anaemia in pregnancy (blood haemoglobin Hb<11.0g/dl) occurs in > 40% of women living in low- and middle-income countries (LMIC) and in some settings in Asia prevalence is >60%. (McCauley et al, BMJ Global Health, 2018; 3(3):e000625) The latest WHO recommendations on antenatal care consider anaemia as the world’s second leading cause of disability and one of the most serious global public health problems (WHO Geneva 2016 ) .Although globally the focus has largely been on anaemia in pregnancy resulting from either iron deficiency or malaria, this is an incomplete approach at best. Iron deficiency is hard to measure and confirm as; i) this requires a functioning laboratory to be in place, ii) indicators for iron deficiency are influenced by the presence of concurrent infection, or, iii) repeated measures of Hb are needed to check whether the anaemia is responsive to treatment with iron. By contrast, malaria is relatively easy to diagnose via rapid diagnostic tests or microscopic examination of a stained blood smear slide. The handful of studies which have comprehensively assessed aetiology of anaemia in pregnant women demonstrate that anaemia is most commonly the result of complex multiple underlying factors including nutritional deficiencies as well as infectious diseases. Both nutritional deficiency and other infections (malaria, tuberculosis) are more likely with HIV-infection which itself can lead to anaemia probably through direct suppression of erythropoiesis.Hull et al show what was possible in a real-life clinical practice setting. This example of integration of research into clinical practice is laudable and is illustrative of how such integration could result in better services being made available for women in LMIC where burden of disease is high, but diagnostic tests are largely unavailable. It is sobering to realise that the majority of women world-wide will still only be screened for anaemia during pregnancy using ‘conjunctival inspection’ which is highly inaccurate. (van den Broek et al. Bull WHO 1999; 77(1):15-21) Rapid diagnostic tests are available for Hb, malaria, syphilis, HIV and, more recently, for tuberculosis. We are doing women a dis-service if we cannot offer at least these basic diagnostic tests as part of antenatal care.To prevent anaemia during pregnancy, the ‘fall-back’ position is to offer all women daily iron prophylaxis (30-60mg elemental iron) - with luck tablets are available that include folic acid (0.4mg) - along with presumptive treatment of malaria (various regimes) in endemic areas. Multi-micronutrients (including the required amount of iron and folic acid) might actually be better but cannot be recommended because of lack of evidence and they are still three times as expensive as iron and folic acid supplementation alone (3$ vs 1$ approximately).WHO recently recommended a better understanding of the aetiology of anaemia. A search on PubMed shows a clear lack of papers on the topic and more good research is needed. Investment in the antenatal care package offered to women is also much needed if we are aiming for a global ‘Health for All’.

Key Points: 1. We have identified ambiguity in the current guidance on thyroid MDT’s, and have also found nationwide variation in compliance with this. 2. We recommend: a. All surgeons undertaking thyroid surgery should complete a minimum of 20 thyroid procedures per year, and this should also form part of surgeons’ annual appraisal. b. All surgeons should contribute data to UKRETS (unless prevented by local legal frameworks) and this should form part of surgeons’ annual appraisal and be audited by individual MDT’s and regional cancer networks. c. Thyroid MDT’s should be held weekly where possible, with a minimum frequency of fortnightly. d. The core membership of a thyroid MDT (stand alone and joint) should include thyroid surgeons, specialist radiology, endocrinology, nuclear medicine, nurse specialists, histopathology +/- cytology and clinical oncology.

A document by Mark Wilkie. Click on the document to view its contents.

Understanding the spatiotemporal changes in soil organic carbon (SOC) and their driving factors is an important prerequisite for decision-making in maintaining sustainable agricultural development and addressing climate change. A total of 1219 cropland topsoil SOC data (0-20 cm) collected from southern Jiangsu Province of China in 1980, 2000, and 2015, and geostatistical sequential Gaussian simulation were used to identify the changes in the spatiotemporal patterns of SOC during the period of 1980-2015. Results showed that the changes in SOC within the different time periods were significantly different, with a net increment of 3.65 g kg-1 during the period of 1980-2000 and a net decrement of 2.32 g kg-1 during the period of 2000-2015. Significant SOC accumulation occurred throughout the study area during 1980-2000, while SOC decline became predominant in the southeast during 2000-2015. Overall, the SOC contents for 60% of the study area increased significantly over the entire 35-year period. The SOC increase during the first two decades (1980-2000) was largely attributed to the increasing soil C input that resulted from the enhanced crop productivity by chemical fertilizers, while the stagnant soil carbon inputs associated with the rapid urban expansion were the primary reason for constraining cropland SOC accumulation in the subsequent 15 years (2000-2015). These findings highlight the importance of balancing agricultural development and urbanization processes to maintain SOC levels, and may also provide some guidance for planning cropland soil C management strategies in many areas that are undergoing similar urbanization processes.

Importance: Tumor encasement of the common carotid artery (CCA) and/or the internal carotid artery (ICA) in patients with advanced head and neck tumors represents a significant surgical challenge. At present, there are few reports on the treatment approach that can achieve the maximal oncological resection and reduce the difficulty of operation without affecting the carotid artery blood flow. Objective: To examine whether the combination of oncologic complete tumor resection and intravascular covered stent placement is more advantageous in the management of advanced head and neck cancer. Design, Setting, and Participants: Five patients with advanced head and neck squamous cell carcinoma (AHNSCC) invading one side of the carotid artery were retrospectively enrolled. The contrast-enhanced computed Tomography (CT) and angiography were performed to assess the severity of extrinsic tumor compression to the carotid artery. Covered stent was placed intra-arterially at least 1 cm proximal and distal beyond the area of tumor involvement. The tumor and the involved carotid artery were resected, and pectoralis major flap transfer was utilized for coverage of the great vessels supported with intra-arterial covered stent. Main Outcomes and Measures: Efficacy of oncologic complete tumor resection combined with endovascular stent placement. Results: The post-stenting demonstrated an improvement in the appearance and caliber of the affected carotid artery. Four patients experienced transient bradycardia and hypotension. All five patients underwent R0 resection. Postoperatively, the flap all had rich vascularity and healing. Three patients underwent adjuvant radiotherapy or chemoradiation. With median follow-up 6.5 months, one patient died of multiple organ failures at 6.5 months after surgery; one patient developed tracheal stoma recurrence and treated with salvaged surgery; the three other patients had no disease recurrence in their last follow-ups. Conclusions and Relevance: Surgical resection with intravascular covered stent placement could potentially achieve the maximal oncological resection without compromise carotid artery blood flow in patients with carotid artery encased head and neck cancer.

Objectives: To evaluate clinical characteristics and prognosis of patients presented with ventricular tachyarrhythmia (VTA) during the course of acute coronary syndrome (ACS) and to analyze it according to period of presentation. Background: VTA is an infrequent yet serious complication of ACS. There is limited data regarding the incidence and prognostic implications of VTA in the last decade as compared with the previous decade. Methods: We evaluated clinical characteristics, major adverse cardiovascular events, short and long- term mortality of patients hospitalized with ACS who were enrolled in the Acute Coronary Syndrome Israeli Survey (ACSIS) during the years 2000-2016. Patients were classified into three groups: no VTA, early VTA (≤48h of onset) and late VTA (>48h of onset). Data were analyzed according to decades of presentation (current decade vs. previous decade). Results: The study population comprised 15,200 patients. VTA occurred in 487 (3.2%) of patients. Early VTA presented in 373/487 (77%) patients and late VTA in 114/487 (23%) patients. VTA’s, occurring in ACS patients were associated with increased risk of in-hospital, 30-days, 1-year and 5-year mortality rates during both early and late periods in compared with no VTA. Moreover, late VTA was associated with the highest mortality rate with up to 65% in 5-year follow up (p<0.001). Nevertheless, late VTA was associated with lower mortality rate in the current decade (2008-2016) compared with last decade (2000-2006). Conclusions: Any VTA following ACS was associated with high short and long-term mortality rate. However, over the past decade there has been a significant improvement in survival rates, especially in patients with late VTA. This may be attributed to early and invasive reperfusion therapy, implantable cardioverter defibrillator implantation and better medical treatment.

Here we describe a case involving an elderly man with Citrobacter freundii-associated infectious rupture of a dissecting thoracoabdominal aortic aneurysm. We performed emergency thoracoabdominal aortic replacement using a rifampicin-soaked prosthetic graft and omental flap wrapping. The patient was discharged on postoperative day 255, although he experienced pseudomembranous enteritis and paraplegia.

Exploring the driving factors of ecosystem services (ESs) trade-offs/synergies is crucial for ecosystem management, especially in ecological conservation red line (ECRL) areas that maintain regional and national ecological security. Soil conservation (SC), water yield (WY) and carbon sequestration (CS) were simulated in the Beijing ECRL areas. Geographical weighted regression was used to explore the trade-offs/synergies, and the geographical detector was applied to quantitatively identify their driving factors. Results show that (1) the SC and CS show marked synergy which characterized more than 80% of each ECRL area; the proportion of the space area of trade-off and synergy between SC and WY, and WY and CS was roughly 3 to 7 and 4 to 6 in each ECRL area, respectively. (2) The synergy of the three pairs of ESs was most sensitive to terrain factors. The precipitation erodibility of soil and its necessity for vegetation make it a determinant of the trade-off between SC and CS; temperature was the determinant in the trade-off between WY and CS, with an explanatory power of 32.8%; potential evapotranspiration was best able to explain the spatial distribution of the trade-off between SC and WY. (3) The interaction between precipitation and other factors had the greatest explanatory power on the spatial relationship between SC and WY. Precipitation and relief amplitude are the main interactive factors respectively affecting the spatial trade-off and synergy between SC and CS. The trade-off and synergy between WY and CS were most sensitive to the interaction between climate factors and terrain factors.

Hypokalemia can be multifactorial. When the primary driver of hypokalemia is obvious it is easy to miss other contributing causes that could be vital to optimal patient management and outcomes. Our case report highlights the importance of recognizing recurrent, refractory hypokalemia as a diagnostic clue to thyrotoxic periodic paralysis.

Background Despite significant advancements in operative techniques and myocardial protection, triple valve surgery (TVS) remains a formidable operation with a relatively high in-hospital mortality. We evaluated the prognostic value of Model for End-stage Liver Disease score including sodium (MELD-Na) for mortality after TVS and its predictive value when incorporated in the EuroSCORE risk model. Methods We performed a retrospective cohort study of 61 consecutive patients who underwent TVS from November 2005 to June 2016. Demographics, clinical, biochemical, and operative data were collected and analysed. Results Median follow-up duration was 8.0 years. 70.5% of patients suffered from rheumatic heart disease. 86.9% underwent mechanical double valve replacement with tricuspid valve repair. There were six operative deaths (9.84%), with the most common cause of death being multiorgan failure (83.3%). 26.2% had a moderately elevated MELD-Na score of 9 to 15, and 4.9% had a severely elevated score of >15. Patients with a MELD-Na >9 had a higher unadjusted rate of operative mortality, prolonged ventilation, need for dialysis and acute liver failure after TVS. Hierarchical logistic regression was performed using logistic EuroSCORE as the base model. After risk adjustment, each point of MELD-Na score increase was associated with 1.405 times increase in odds of operative mortality. The regression analysis was repeated by incorporating individual components of the MELD-Na score, including bilirubin, sodium, and albumin. All three biochemical parameters were significantly associated with operative mortality Conclusion MELD-Na score as a quantifier of hepatorenal dysfunction is sensitive and specific for mortality after triple valve surgery.

Necrotizing soft tissue infections (NSTIs) are life-threatening conditions burdened with high mortality. They’re often associated to a poor prognosis if early diagnosis and prompt treatment is not warranted. Treatment is always medical, often surgical and sometimes with hyperbaric oxygen.

ABSTRACT Objectives Anecdotal evidence suggests that oropharyngeal squamous cell carcinoma (OPSCC) should be suspected in patients presenting with symptoms of peritonsillar abscess (PTA) or cellulitis (PTC). The aim of this study was to estimate the prevalence of OPSCC in patients presenting with symptoms of PTA/PTC. Method, Setting and Participants We retrospectively identified all adults with a coded diagnosis of PTA or PTC who presented between 2012-2016 inclusive, across six ENT units in ——–. Records were compared to that of the centralised regional head and neck cancer database. The clinical records of a subset of patients were reviewed for the purposes of data validation. Results A total of 1975 patients with PTA/PTC were identified. Three patients were subsequently diagnosed with OPSCC. None of the three actually had an objective underlying diagnosis of PTA/PTC on the same side. The prevalence of OPSCC in patients admitted with symptoms of PTA/PTC was 0.15%, or approximately 1:650 admissions. The records of 510 patients who presented over a one-year period (2016) were reviewed in even greater detail. There were 298 patients with PTA (59.4%), 151 with PTC (29.1%) and 61 had an alternative diagnosis (11.9%). High risk features (age ≥40, tonsillar asymmetry or tonsillar lesion) were present in 106 patients (24%). Urgent follow up was expedited for 77 patients (73%). Conclusion This study estimates the risk of OPSCC in patients with peritonsillar symptoms. The prevalence is low, even in a region with a relatively heavy disease burden. Clinicians should, however, retain a high level of suspicion in patients with persistent symptoms.

The novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) still has serious negative effects on health, social life, and economics. Recently, vaccines from various companies have been urgently approved to control SARS-CoV-2 infections. However, any specific antiviral drug has not been confirmed so far for regular treatment. An important target is the main protease (Mpro), which plays a major role in replication of the virus. In this study, Gaussian and residue network models are employed to reveal two distinct potential allosteric sites on Mpro that can be evaluated as drug targets besides the active site. Then, FDA-approved drugs are docked to three distinct sites with flexible docking using AutoDock Vina to identify potential drug candidates. 14 best molecule hits for the active site of Mpro are determined. 6 of these also exhibit high docking scores for the potential allosteric regions. Full-atom molecular dynamics simulations with MM-GBSA method indicate that compounds docked to active and potential allosteric sites form stable interactions with high binding free energy (∆Gbind) values. ∆Gbind values reach -52.06 kcal/mol for the active site, -51.08 kcal/mol for the potential allosteric site 1, and -42.93 kcal/mol for the potential allosteric site 2. Energy decomposition calculations per residue elucidate key binding residues stabilizing the ligands that can further serve to design pharmacophores. This systematic and efficient computational analysis successfully determines ivermectine, diosmin and selinexor currently subjected to clinical trials, and further proposes bromocriptine, elbasvir as Mpro inhibitor candidates to be evaluated against SARS-CoV-2 infection

A psychological assessment using biofeedback was performed for an adjustment disorder inpatient who showed less verbal and non-verbal expressions, and experienced difficulty in receiving favorable results from treatment. The assessment revealed hidden problems behind the symptoms. She was subsequently discharged, after which no clinical intervention was required, including medication.

1. The use of machine learning technologies to process large quantities of remotely-collected audio data is a powerful emerging research tool in ecology and conservation. 2. We applied these methods to a field study of tinamou (Tinamidae) biology in Madre de Dios, Peru, a region expected to have high levels of interspecies competition and niche partitioning as a result of high tinamou alpha diversity. We used autonomous recording units to gather environmental audio over a period of several months at lowland rainforest sites in the Los Amigos Conservation Concession and developed a Convolutional Neural Network-based data processing pipeline to detect tinamou vocalizations in the dataset. 3. The classified acoustic event data are comparable to similar metrics derived from an ongoing camera trapping survey at the same site, and it should be possible to combine the two datasets for future explorations of the target species’ niche space parameters. 4. Here we provide an overview of the methodology used in the data collection and processing pipeline, offer general suggestions for processing large amounts of environmental audio data, and demonstrate how data collected in this manner can be used to answer questions about bird biology.